Flashcards in Oral Medicine V - Brennan's Bespoken Bane Deck (116):
Dyskinesias affect the jaw
What is the ideal pre-Tx drug regimen for Parkinson's pts?
Take meds 60-90 minutes prior to appt
*peak response period
**also, brief visits
An estimated 2.6 million Americans have A-fib, number is increasing, and is responsible for ______% of all Strokes
4 comorbidities to A-fib
Coronary artery disease
3 Therapies for A-fib
Meds (Antithrombotics, combo, alternative)
New Comparative Study, Tx of CVA can be safely administered w/in what time period?
As long as what?
A few weeks of CVA
Kept under optimal medical surveillance
Most common Inherited Clotting Disorder:
(1 in 5,000 male births)
(1 in 30,000 male births)
Hemophilia A is a Factor ___ deficiency (80%)
Hemophilia B is a Factor _____ deficiency (13%)
6% is a factor ____ deficiency
Vitamin K rich foods are
If you lack one coagulating factor it is...
If you lack multiple coagulating factors it is....
4 Vitamin K factors made in the LIVER:
Factor XII, XI, IX
Intrinsic system/Tissue Factor pathway
Extrinsic system/Contact pathway
3 lab tests for Coagulation Disorders
aPTT - Activated Partial Thromboplastin Time
PT - Prothrombin Time
aPTT tests the ______ system. What 4 factors?
PT tests the _______ system. What 5 factors?
Platelet Count deals w/ primary _____
Intrinsic VIII, IX, XI, XII
Extrinsic VII, V, X, prothrombin II, fibrinogen I
Some pts might not be forthcoming about bleeding disorders - what is an important question to ask?
Do you bleed or bruise easily?
5 Uses for Warfarin
*what 2 have higher anticoagulation and higher risk of morbidity
Prosthetic Heart valves
Hx deep venous thrombosis
What INR and PT levels would you not worry about (discontinuation not necessary for minor OS)
INR < 3.5
PT < 20 seconds
Primary concern for pts on Warfarin:
Recourse for excessive bleeding:
Order/review lab values - perioperative change likely
GelFoam/thrombin, bone wax, Amicar/Tranexamic acid rinses
PT < 20 seconds, INR < 3.5
These measurements should be takend w/in _____
You can make changes to anticoagulation therapy
3 Issues w/ Warfarin:
Narrow therapeutic window
What consumables increase the effects of Warfarin?
Green, Vitamin K rich foods
Pain med interactions w/ Warfarin:
ASA, NSAIDS, Acetaminophen
Tetracycline, ampicillin, amoxicillin/clavulanic acid (augmentin)
What Abx should you take w/ pt on Warfarin? (2)
Pen V or Clindamycin
Lit supports altering anticoagulant regimen prior to dental procedures and surgery
*go by 3.5 rule
Clinical judgement, experience, training, and accessibility to appropriate bleeding management strategies are all important components in any treatment decision
Frame and put on wall
3 Antiplatelet agents:
ASA (and NSAIDS)
Antiplatelets are used primarily for prophylaxis of:
Secondary prevention of adverse ________
in pts with Hx of _______, _______, and ______
Coronary thrombosis, Stroke, Unstable Angina
Do NOT mix up coagulation factors w/ Anti-Platelets - What does INR measure?
NOT platelets (ASA, etc)
Best test for ASA platelet effect is PFA 100 or Ivy bleeding time
Not a problem unless Bleeding time is greater than ______
NSAIDS will increase bleeding time how?
Generally you must wait 3 half lives (w/ wide variance between drugs)
6 ways to increase clinical risk of bleeding through antiplatelet activity:
Clinical recommendation for pts on Antiplatelet therapies:
Little/No indication to interrupt antiplatelet drugs for dental procedures
It is not necessary to interrupt low dose aspirin therapy for simple dental extractions
*really any ASA dose
Drug Eluting Stents (DES) is often clopidogrel, plavix, etc and when combined with ASA...
Decreases cardiac events after stenting
DES, premature discontinuation of antiplatelet therapy greatly increases the risk of what 3 things?
DES usually has ASA/Plavix dual Tx for how long after Stent placed?
Postpone Elective surgery for how long?
If surgery cannot be deferred, what do?
continue ASA perioperatively
3 reasons for Warfarin replacement drugs:
Wide therapeutic index
Few Drug/Food interactions
Predictable anticoagulant response at fixed doses
3 new oral Anticoagulants (Warfarin replacements)
New oral Anticoagulants (Xarelto, etc) have what major flaw
No reversal agent
What is the reversal agent for Warfarin?
If pt taking new Anticoagulants, what 3 lab tests do you need prior to surgery?
Warfarin acts on what 4 clotting factors:
Unfractioned Heparin on what 2:
Rivaroxaban (and Apixaban):
VIIa, IXa, Xa, Thrombin
2 new drugs act on Factor X:
1 new acts on Factor II (Thrombin):
It does not appear Dabigatran discontinuation is necessary (if renal function, etc ok)
Type 1 diabetics have a deficiency of insulin secondary to destruction of what cells?
Type II is either faulty receptors to insulin or antibodies to those insulin receptors or insulin itself
In either case, what is the result?
Hyperglycemia, short term polyphagia, polyuria, polydipsia, ketoacitosis/hyperosmotic coma
What is the long-term consequence?
*and deposition, delayed healing, infection
Diabetes Diagnosis, blood Glucose:
HbA1c must be what in well-controlled diabetics:
Xerostomia, Infection, poor wound healing, increased perio/caries, etc
There is a significant bleeding risk in Diabetes
Epinepherine concern in Diabetes:
epi in LA increases blood Glucose
Well-controlled diabetics can tolerate dental care _____
If cardiac complications...
Diabetes: Morning appts, pts eat normally. Have what to monitor?
What in case of hypoglycemia?
In uncontrolled diabetes, provide what care only?
Controlled diabetics Abx
like everybody else
heightened risk for Infection (Use post-op Abx)
Normal thyroid feels...
If untreated Hyperthyroidism, avoid...
If untreated Hypothyroidism, avoid...
Hydrocortisone (100-300 mg), CPR, IV glucose Tx for crisis in both Hyper and HypoThyroid
In well-controlled thyroid disease, Tx infections normally
Osteoporosis of alveolar bone, caries, etc
Cretinism, enlarged tongue, etc
Pain to ear, jaw, occiput, dysphagia, enlarged, firm nodular, and tender thyroid
Possible labe tests for organ transplantation Bleeding time:
platelet count, WBC count, hematocrit
AST, ALT, alkaline phosphatase, PT, bilirubin
creatinine, BUN, specific gravity urine, proteins in urine, hematocrit, WBC, pTT
3 important factors in Dentistry to consider in pts w/ transplants:
build-up drugs/toxic metabolites (liver/kidney)
Oral signs of Immunosuppression include HSV, apthous, CMV, candidiasis...
Bone Marrow suppression drug that Increases chance for infection:
affects liver/kidney, causes gingival hyperplasia
Avoid dental care Tx for how long after a Transplant?
prophy Abx, other mods, labs
4 Drugs to Increase Interval/Change after Organ Transplant
Tetracycline (or Doxy)
If Abx prophylaxis, give what ideally?
or Impenem, dosage:
Can't take orally:
What shouldn't be used in Organ Transplant pts b/c of acute Liver Toxicity?
Amoxicillin, 2g orally 1 hr prior
500 mg oral 1 hr prior
Vancomycin, 1g IV infused slowly over 1 hr prior
1g IV infused 1hr infused slowly prior
Apicillin, 2g IV 1 hr prior
metronidazole 500 mg IV 1 hr prior
Transplant issues, anticoagulation via meds, rejection
Stress - may need steroid supplementation if adrenal suppression
Mucositis, viral infection, aphthous, etc
Blood Glc reading = 65
Tx w/ fast acting carbs
Post-op Abx in Diabetes:
only for Uncontrolled
Uncontrolled Diabetic Cardiac Guidelines:
*no subset here, follow Cardiac Guidelines
Fasting Glucose threshold for Diabetes:
126 mg/100 mL
If pt on ASA, what lab test prior to Extraction?
*nothing for Anti-platelets!!!
Warfarin affects what clotting factors (number and name):
VIIa (tissue factor)
Extrinsic, Tissue Factor pathway, what Factor?
Med Consult during Chemo?
Postpone when Platelets below...
or Neutrophils below...
Tx of Uncontrolled Diabetics when?
only during Emergency
Parkinson's, take meds _-_ minuted prior and keep brief
60-90 minutes prior
Old research on stroke, wait....
New research, Tx w/in ____ as long as surveilled
a few weeks
4 Vitamin K dependent factors:
II, VII, IX, X
Clotting factor II:
If on Warfarin, INR <
Should be measured w/in
New drug, Thrombin inhibitor:
3 Factor Xa inhibitors:
Rivaroxaban, Apixaban, Edoxaban
2 Abx ok to use w/ Warfarin:
Asthma, instruct pt to bring Inhaler, consider _____ if severe.
pulse ox during Tx
Ventolin/Proventil (short acting beta 2 adrenergic)
COPD 4 clinical considerations:
Stability of pt
avoid Rubber Dam
Low-flow supplemental Oxygen
Almost everyone w/ Asthma has what Drug Allergy?
Chronic Bronchitis, chronic cough w/ sputum production for what time period?
3 consecutive months
2 successive years
too much CO2 (COPD)
COPD (Stevens-Johnson syndrome)
Unstable COPD pt (below 91% Oxygen) must have what 2 mods?
Stable COPD, ok to use diazepam
must be upright
Early stage tumors:
Pre-cancer oral health exam should be done when?
1 month prior cancer Tx
Common radiation side-effect
Radiation Therapy, dental procedures should be done how long prior?
If ortho bands
Endo in field:
Endo out of field:
avoid removables, fabricate dentures _____ post surgery/radiation
10-14 (idally 21) to heal
Extract, no re-treats
RCT can be done
If chemo, ask Oncologist cancer, stage, palliative/curative, prognosis
Tx schedule (so safe dental Tx can be delivered)
CBC, neutrophil, platelet
If possible, all dental Tx should be done ___ prior to Chemo
Extractions should be done how long prior ideally?
When do you need a Med Consult if pt on Chemo?
If pt on Chemo, when would you postpone Tx? (2 cases)
platelet count < 50,000
neutrophil count < 1,000
When would you schedule a Chemo pt?
17-20 days post Tx (when they feel best)
Hematopoietic stem cell transplantation:
Intentional destruction of Marrow
stem cell transplant
3 types of Hematopeitic Stem cell transplants
Autologous (own cells)
Allogenic (own species)
Syngeneic (identical twin)
HSCT similar guidelines to Chemo
HSCT, delay elective procedures for how long?
Greatest risk of complications:
*180 days autologous, 365 allogeneic for standard care
Painful, ulcerative oral complication of Radiation
Mucositis, xerostomia, candidiasis, osteoradionecrosis,
Mucositis, ural ulceration, anemia, thrombocytopenia, infection, neurotoxicity, osteonecrosis of the jaw, xerostomia
Anticonvulsants can modify the pathologic process and decrease orofacial pain
HSCT prevalence of Oral Complications:
GVHD manifests orally as atrophy, erythema, white striations, plaques (similar to lichen planus), xerostomia, taste changes, formation of mucoceles, and mucosal sclerosis
If neutrophil count is below 50,000, what is needed
All procedures 1 week prior to chemo
17-20 days post